Team B: family practice, emergency medicine, gynecology & obstetrics, occupational & environmental medicine, and pediatrics & adolescent medicine.

FOREIGN BODY BRONCHIOLITIS. April Burks, DO, Gary Dunkerley, MD, and Walter Edge, MD. St. Clare's Hospital Family Practice Residency Practice, Schenectady, NY

Foreign bodies (FB) in the respiratory tract of children are an important cause of respiratory distress in children. More than 500 deaths in children a year in the United States are associated with FB. It should always be considered in any child who presents with respiratory distress. We present the case of foreign body bronchiolitis. A 5month-old male infant was brought to the family health center with inconsolability and low-grade fever for 1 day. The patient was noted to have perioral cyanosis and was sent to the emergency department (ED) for additional evaluation. In the ED, the patient was diagnosed with broncholitis and sent to the general pediatric floor. On admission, the patient was evaluated for sepsis because of the inconsolability and weak cry. A catheterized urine culture, blood culture, chest x-ray, and lumbar puncture were unremarkable. For therapy, the patient was placed on the bronchiolitis pathway with included mist tent, frequent albuterol riebs, and meningeal doses of ceftriaxone. Despite treatment, the patient continued to have respiratory distress with low [O.sub.2] saturation, tachypnea, costal retractions, and inconsolability. The patient was transferred to the pediatric intensive care unit (PICU) at the area's tertiary medical center because he did not response to treatment. At the center, chest x-ray, catheterized urine culture, blood cultures, and a lumbar puncture were all repeated and were negative. The patient was continued on ceftriaxone at meningitis doses, mist tent, frequent albuterol treatments. Since the patient's lab work was negative and he continued to have respiratory distress, inconsolability, and a weak cry, he was thought to be encephalopathic and was started on acyclovir. A PICU registered nurse noticed a radiopaque object in the neck on the repeated chest x-ray and this was pointed out to the medical team. A lateral chest x-ray was obtained, which showed the same object in the same position. An otolaryngolist was consulted who took the patient to the operating room for endoscopy. The patient was found to have a child's hair barrette on top of the glottis. The object was removed, and the patient was placed on decadron for laryngeal edema. The patient recovered completely. The patient was sent home on postoperative day 2. The clinical presentation of bronchiolitis proved to be due to a foreign body in this patient. Primary care physicians should consider a foreign body in the differential diagnosis in all patients who present with clinical bronchiolitis not responding to standard therapy. Clinical reevaluation and a high index of suspicion led to the correct diagnosis in this instance.

NASOPHARYNGEAL SQUAMOUS CELL CARCINOMA MIMICKING SINUSITIS. William Forlano, MD, Ephraim Back, MD, Gary Dunkerley, MD, Angel Fernrin, MD, and Alunad Qadri, MD. St. Clare's Hospital, Schenectady, NY

Nasopharyngeal carcinoma (NPC) is a relatively uncommon malignancy within the United States. It represents roughly only 0.2% of all malignancies. Among cancers of the head and neck it only accounts for 3% to 5% of malignancies. Although rare, it can mimic the symptoms of many much more common diseases when in its early stages. We present the case of a previously healthy 49-year-old white man who initially presented with congested nose, epistaxis, and pain to percussion of maxillary sinuses who was treated with antibiotics for a presumed sinusitis after being evaluated in the emergency room. The patient returned to the emergency room some 3 weeks later with complaints of sore throat, dyspaghia, and epistaxis from the left nare. On further questioning, the patient noted double vision, a 40-lb weight loss over a 5-week period, intermittent fevers mainly in the evening, and pain of the left ear with an associated decrease in hearing from the left ear. The patient had a 50-year pack history of smoking and was a Vi etnam veteran. Physical examination revealed a thin white man with maxillary sinus pain to percussion of the maxillary area. Pupils were equal in size and equally reactive to light accommodation. Extraocular movements were intact. Tympanic membranes were without erythema or effusion bilaterally and landmarks were clearly visible. Exmination of the nares revealed a deviated septum toward the right and congested nares. The anteroseptal area of the left nare showed some tissue that appeared necrotic at the junction of the septum and bony spur. Neck examination revealed a large, hard, nontender movable node at the angle of the right mandible, which measured 4 x 5 cm in dimension. The patient also had several palpable, nontender anterior cervical lymph nodes on the left, each about 1.5 cm in diameter. Several enlarged right posterior cervical nodes were also noted, X-ray of the head showed partial opacification of the paranasal sinuses with a soft tissue mass in the oropharynx near the clivus. Neck soft tissue x-r ays revealed a soft tissue mass destroying the clivus and narrowing the oropharyngeal airway. A CT scan of the head and neck revealed a large destructive bone mass in the neck and anterior portion of the base of the skull with destruction of the clivus and partial involvement of the petrous bone and medial aspect of the temporal bones bilaterally. The mass extended at least 10 cm craniocaudally and had a lateral dimension of 5 cm and an AP diameter of 4 cm. Maxillary sinusitis was also present likely due to obstruction of the maxillary sinus outflow tracks. Cervical lymphadenopathy of the anterior and posterior triangles was also present The patient was taken to the operating room for biopsy of the mass of the nasopharyx. Direct visualization of the nasopharynx revealed a deep ulcerative mass. Several biopsies were obtained of the mass in the nasopharynx and of the necrotic area of the left anterior septum, which all showed infiltrating. nonkeratinizing. moderately differentiated squamous cell carcinoma. Init ial diagnosis of nasopharyngeal carcinoma is often difficult due to the fact that the disease may often have few presenting symptoms until the process is advanced and the symptoms present are frequently vague and can mimic symptoms of other disease processes. This case highlights the need for family physicians to consider more involved pathology when faced with a clinically suspected case of sinusitis.

THE MIGRATING CRACK-PIPE. Promita Roychoudhury, MD, William Anyaegbunam, MD, and Gary Dunkerley, MD. St. Glare's Hospital, Schenectady, NY

We present a case of a 34-year-old white female G6, P5 seen in the ER with a one clay history of vaginal bleeding and pain. The patient stated that she got fairly intoxicated at a party the night before, and, on the way home, inserted her 'crack-pipe' in the vagina for safe-keeping.' She then fell over a fence and sustained a vaginal injury. She somehow controlled the bleeding with intra-vaginal icepacks. Nonetheless, the bleeding persisted so she presented to the ER. A diagnosis of foreign body impaction in the vagina was suspected and a gynecologist was consulted. Vaginal exploration under conscious sedation was performed and multiple superficial lacerations were noted in the vagina but no perforation of the vaginal wall or impacted foreign body was seen. Intraoperative x-ray of the pelvis with a vaginal speculum in place demonstrated the foreign body to be supra cervical. The vaginal lacerations were irrigated and repaired and a foley catheter was placed which drained rusty urine. A CT was then performed a nd suggested the foreign body was intra-abdominal but extra-peritoneal, and impacted in the right lateral fornix. Exploratory laparotomy was performed, the space of Retzius was entered, but no extra-peritoneal foreign body was detected. The vaginal fornices were also inspected and demonstrated no evidence of foreign body or perforation. A foreign body was palpated, however, within the urinary bladder. Cystostomy was performed, the foreign body was retrieved, and gross inspection confirmed a metallic cylinder. The indwelling foley catheter was left in place, long term antibiotics were started, and the patient was released after two days in hospital. At her postoperative visit, the patient changed her story. Following the party she was approached by the police and she inserted the crack pipe in her vagina. Due to continuous urinary incontinence the patient cut herself in an attempt to remove the crack-pipe. Presumably, the foreign object was inadvertently inserted in the urethra and then migrated to the urinary bladder. To our knowledge this is the first time a crack pipe has been accidentally lost in the urinary bladder. The case illustrates how an unreliable history without substantiation by physical examination and reliance on CT scan for precise localization of foreign object can misdirect surgical management. With hindsight, an ultrasound scan of the urinary tract may have been a better option and the patient would have been better served by cystoscopic retrieval of the foreign object.

NEW-ONSET SEIZURE CAUSED BY ASTROCYTOMA. Stephen Offord, MD, Richard Brooks, MD, Gary Dunkerley, MD, and Frank Genovese, MD. St. Glare's Hospital, Schenectady, NY.

We present the case of a new onset seizure due to glioblastoma multiforme. Of primary CNS malignancies, astrocytomas are most common, and a grade IV astrocytoma, glioblastoma multiforme, can present most dramatically. Our case illustrates not only a dramatic presentation of glioblastoma multiforme, it stresses the importance of MRI in addition to CT in the diagnostic workup of a seizure. A 62-year-old white man was found on his bedroom floor minimally responsive, pale, and diaphoretic. He had a PMH remarkable only for diet controlled DM. According to his wife, the patient had been well up until the event. On arrival, EMS observed three brief generalized tonic clonic seizures with urinary incontinence. PE, including a full neurologic examination, revealed only the patient's inability to name the month or year. CBC and chemistries were remarkable only for a blood sugar of 280 mg/dL and a bicarbonate of 12.8 mEq/L. Cardiac isoenzymes were normal and EKG demonstrated no acute changes. Head CT without contrast, do ne on admission, was negative. EEC demonstrated diffuse generalized slowing. Clinically, the patient began to improve. But on hospital clay 2 he complained of a severe, persistent, headache. An MRI was then ordered which showed a 2.1 x 2.0 x 2.0 cm irregular ring enhancing lesion in the posterior aspect of the left panetal lobe. It produced a mass effect with surrounding cerebral edema. Biopsy of the lesion confinned glioblastoma multiforme. A space occupying lesion should be on every differential of new onset seizures in an adult. Primary CNS tumors, however, are relatively rare. More often adult CNS tumors are metastatic. Astrocytomas are the most common primary malignancy. Typically, they present in the fourth to sixth decade with a headache, seizure, or focal neurologic deficit. Lower grade astrocytomas present with more subtle neurologic deficits such as weakness in one hand. Higher grades, with glioblastoma multiforme being the most malignant, can present abruptly. In older adults, they can present de n ovo, without progression from a lower grade astrocytoma. Such patients, like ours, may have no symptoms 1 day, and profound deficits the next. This case highlights not only an acute presentation of a primary CNS tumor, but also the preference of MRI over CT for identifying CNS lesions. Primary care physicians should consider the use of MRI as the imaging of choice for new onset adult seizure disorders.

UNUSUAL PRESENTATION OF CARCINOMA OF THE CERVIX. Asha Shah, MD, Gray R. Dunkerley, MD, William Anyaegbunam, MD, and Ephraim Back, MD. Department of Family Practice, St. Clare's Hospital, Schenectady, NY.

Carcinoma of the cervix is the third most common malignancy of the female genital tract in the United States, with an estimated 12,800 new cases and 4,800 deaths reported in 1999. We present the case of a 70-year-old white woman with an atypical presentation for carcinoma of the cervix. She presented with a 2-week history of bilateral leg swelling and fatigue. She has had vaginal spotting on straining for the last 2 years but denied vaginal discharge, pelvic pain, or urinary symptoms. The patient has a 50 pack-year history of smoking. She has been celibate snce her divorce 28 years before presentation. She had refused Pap smear and pelvic and rectal examinations for the past 10 years. Her siser was diagnosed with invasive cancer of the cervix at the age of 75. On physical examination, she had 3+ pitting edema in both legs. Routine blood work was significant for elevated BUN and creatinine of 140 and 9.3, respectively and anemia (Hb 7.8, Hct 23.1). The patient was admitted with a diagnosis of acute renal failu re of unknown etiology. Renal ultrasound revealed large bilateral hydronephrosis with hydroureters. Computed tomography of the abdomen confirmed these findings with no mass or adenopathy noted in the pelvis. Chest x-ray showed mild congestive heart failure and upper lobe nodule in the left lung. Pelvic examination revealed a friable mass at the cervix with right parametrial thickening. Clinically, the patient was diagnosed with stage III cervical cancer. Histopathology of the cervical biopsy specimen revealed invasive squamous cell carcinoma of the cervix with moderate to poor differentiation. Urine culture was positive for Klebsiella but no malignant cells were seen in the urine specimen. Bilateral percutaneous nephrostomy was done for obstructive uropathy. On day 13 of hospitaliztion, acute renal failure had improved with BUN of 62, and creatinine of 3.7. Different treatment options were discussed with the patient. The patient was discharged from the hospital for outpatient chemotherapy and radiotherapy. Th is atypical presentation of carcinoma of the cervix as obstructive uropathy and acute renal failure emphasizes the importance of screening cytology evaluation and pelvic examination of all women, even over 65 years of age.

AMNIOTIC FLUID EMBOLISM: FAMILY PRACTICE PERSPECTIVE. Promita Roychoudhury, MD, Gary Dunkerley, MD, David Cryns, DO, Omar Mendez, MD, and Jack Parillo, MD. St. Clare's Hospital, Schenectady, NY.

Amniotic fluid embolism syndrome (AFES) is a rare catastrophic condition of pregnancy that can occur at or shortly after delivery. The incidence is estimated at 1 in 30,000 deliveries. The major clinical features are hypoxia, respiratory failure, cardiogenic shock, and disseminated intravascular coagulation. We present the case of a 19-year-old (G4, P1) with known placenta previa, who presented to the hospital with painless vaginal bleeding at 36+ weeks of gestational age. On admission, the patient was stable, but initial blood work was consistent with a mild coagulopathy (FDP [greater than]40 [normal [less than]40]). The patient was taken for C-section and a viable female was delivered. Intraoperatively, the estimated blood loss was about 1,700 mL. During and after the operation, the patient was hemodynamically unstable requiring transfusion of 4 units of packed red blood cells (PRBC). The patient was transferred to the ICU where she was later intubated. At that time, her fibrinogen was 25 mg/dL (normal 200 to 400), and FDP [greater than]40. Despite appropriate therapeutic interventions (units of PRBC, FFP, cryoprecipitate, and vasopressors), the patient remained hemodynamically unstable, suffered a cardiopulmonary arrest and died. Postmortem examination was consistent with AFES. Differential diagnosis of APES includes pulmonary embolism, sepsis, postpartum hemorrhage, anaphylaxis, aspiration of gastric content, and myocardial infarction. It is thought that amniotic fluid in the venous circulation results in occlusion and vasospasm of maternal pulmonary vasculature with subsequent left ventricular failure, cardiogenic shock, and consumptive coagulopathy. Autopsy findings include mucin and squamous cells in the pulmonary vasculature, but these are not considered pathognomonic. AFES carries a 60% to 90% maternal mortality and is without specific treatment other than supportive care. This case highlights the need for family physicians to consider APES when sudden maternal cardiorespiratory collapse occurs. This art icle reviews the predisposing factors, pathogenesis, diagnosis, and management of this rare, usually fatal condition.

COUNTDOWN TO ECSTASY. Ronald J. Dougherty, MD. Tully, NY.

In the past 10 years of the "drug war," adolescent and young adult substance abuse has not decreased. Over the past 2 years, according to the 2000 annual report, National Drug Control Strategy, reported that 8th, 10th and 12th graders have all reported an increase in the use of marijuana. First-time cannabis abuse doubled from 1991 to 1998. Average age for substance abuse has dropped from 17.8 to 17 years. The price of cannabis has fallen dramatically and potency has increased. Federal cannabis seizure has increased by 2000% in the past 2 years. First time cocaine users from 1991 to 1997 had nearly doubled. Average age of use dropped from 21 1/2 to 20 years of age. Current cocaine use shows a slight decrease. The price of cocaine has dropped significantly and cocaine purity has markedly diminished. The numbers of cocaine deaths from cardiac arrests, seizures and coronary occlusion have remained unchanged. There appears to be less street homicides which could be attributed to the decrease in the "cocaine wars." Heroin use has had a big jump from 1991 to 1998. Part time users are up 60% and the average age for first time heroin use dropped from 24.6 to 17.6 years of age. The number of heroin fatalities has increased slightly. Heroin has gained popularity with young people because it can be smoked or inhaled, but unfortunately still can be fatal. There has been a marked increase in abuse and fata lities with inhalants in teenagers including the use of scotchguard, glue, gasoline and kerosene. There had been a 10 year drop up until the last 2 years. There has been a 300% increase in the use of the so-called "club drugs." These include GHB, which has contributed to some recent fatalities, and arrests and convictions, usually of young males. In addition, Rophypnal, the date rape drug appears to be Leveing off as far as causing fatalities. In many instances the alleged date rape drug overdose which leads to the person going to the ER, turns out not to be Rohypnal, but rather other benzodiazepines or other substances. MDMA (methylenedioxymethamphetamine) otherwise known as Ecstasy or XTC, has had explosive use and abuse among teenagers and young adults. MDMA, which is both a hallucinogen and a stimulant, not uncommonly can cause, upon ingestion, adverse effect upon serotonin causing anxiety, depression, paranoia, confusion, hallucinations and sleep disturbance. In addition, physical adverse effects can inc lude cardiac arrhythmia, dehydration, hypertension, renal failure and death. Some MDMA consumers end up dying from malignant hyperthermia when the drugs effects are intensified by dancing in hot smokey clubs, and the consumer fails to consume enough water to protect their kidneys and their brain. Long term use of MDMA has been reported to cause damage in the brain, especially damage to the hippocampus and the neocortex. When teens are asked what is causing drug abuse to increase, 44% report peer pressure and 15% personal and family problems. When these same teens were asked what helps decrease drug abuse, 43% responded that drug education helps. 74% of 4th graders said they wanted more details from their parents or professionals about drugs, and teens who received strong anti-drug messages at home are reported to be 42% less likely to use drugs than those who did not. Perhaps it is time to listen to our youth as to what works and what doesn't work. $19 billion dollars spent during the last administration's dr ug war did not work, and the previous administration spent $9 billion dollars with little to show for their expenditure, which could be better implemented in drug education, prevention and treatment.

RECURRENCE OF COLON CARCINOMA DETECTED BY ANNUAL PAP SMEAR SCREENING. D. Akingba, D. G. Gallup, and J. J. Burke II. Department of Obstetrics andGynecology, Mercer School of Medicine, Memorial Health University Medical Center, Savannah, Ga.

Malignant cells detected by Pap sear may be the result of metastasis of extra uterine cancers to the uterine cervix. The most common tumor types include ovarian, gastrointestinal and breast. We present a case of recurrent colon carcinoma which was found by an annual screening Pap smear. The patient is a 59 year old African-American female who was originally diagnosed with a T2, NO, MO adenocarcinoma of the rectum in November 1998. She was treated primarily with a low anterior resection of the sigmoid colon and no adjuvant therapy. In February 2000, a Pap smear revealed a high-grade intraepithelial lesion (HGSIL). Further evaluation by colposcopically directed biopsies demonstrated normal tissue. Because of the Pap smear/colposcopy discrepancy, a loop electrical excision procedure (LEEP), endocervical curettage (ECC) and dilatation and curettage were completed. Final pathology revealed normal ectocervical and endometrial tissue. However, the ECC revealed several small, markedly atypical glandular fragments sus picious for adenocarcinoma. A computed tomographic examination of the abdomen and pelvis was completed, revealing a mass effect of the cervix. Colonoscopy revealed recurrent adenocarcinoma of the colon 10 cm from the anal verge at the previous colonic anastomosis. The patient underwent an en block anterior-perineal resection of the uterus, cervix, ovaries, rectum and anal tissue 'with a descending end colostomy. Final pathology revealed recurrent adenocarcinoma of the colon, invading through the wall of the colon into the endocervical region. The patient was further treated with whole pelvis external beam radiotherapy completed in October 2000 and has no evidence of disease. This case outlines a rarely reported recurrence of colon carcinoma detected by Pap smear screening. When a patient presents with a history of prior malignancy, abnormal Pap smear screening should alert the physician to the possibility of recurrence, with metastasis to the female reproductive tract.

MORBIDITY OF UNSCHEDULED POSTPARTUM HYSTERECTOMIES. Lama Tolaymat, MD, Shadi Tolaymat, BS, Rich, BS, Victor Hugo Gonzalez-Quintero, MD, and Samir Beydoun, MD. University of Miami, Jackson Memorial Hospital, Miami, Fla.

To describe our experience in postpartum hysterectomies at Jackson Memorial Hospital. Women who underwent hysterectomies within the first 6 weeks postpartum during the period of January 1st 1997 to December 31st 1999 were identified. After IRB approval, the charts were reviewed. Characteristics such as indications for hysterectomy, time of hysterectomy, estimated blood loss and hematocrit decrease were collected. A total of 25 women had hysterectomies within the first 6 weeks of delivery at Jackson Memorial Hospital during the study period. A total of 18 charts were available for complete review. The mean maternal age at delivery was 33.5 years and the mean gestational age at delivery was 36.2 weeks. Ninety four percent of the women had prenatal care starting at a mean gestational age of 10 weeks. Except for one patient who had a scheduled cesarean hysterectomy for cervical carcinoma, the indication for all other hysterectomies was uncontrolled bleeding. Sixty seven percent of these women delivered by cesarea n section. Those who underwent a hysterectomy more than 6 hours after delivery were delivered by cesarean section. The mean estimated blood loss was 3617 cc, and 89% of the women received blood products. Those who had a hysterectomy within 6 hours of delivery had a mean drop in hematocrit from pre delivery to pre transfusion of 9.6% and their mean hematocrit at time of discharge was 28%. The mean hospital stay, in those who underwent hysterectomy during the delivery admission, was 7.6 clays. Abnormal placentation was seen in 23% of specimens, all of which had a history of previous cesarean section. Fibroids were seen in 11%, and no abnormal pathology was identified in the rest (66%). Fifty percent of the patients had a history of at least one cesarean delivery. Uncontrolled bleeding is the most common indication of postpartum hysterectomy. It is a highly morbid procedure associated with high risk of needing transfusion, and long hospitalization.

HEMATOGENOUS SPREAD OF STAPHYLOCOCCUS AUREUS CAUSING CHORIOAMNIONITIS AND FETAL DEATH WITH INTACT MEMBRANES. M. E. Herman, DO, M. Bavaro, MD, and W. J. Coyle, MD. Naval Medical Center, Portsmouth, Va.

Chorioamnionitis is a general term used to describe infection of the fetus, membranes, and amniotic fluid. It is usually caused by an ascending infection from the maternal genital tract. Other etiologies include hematogenous spread of maternal infection, iatrogenic infection from prenatal procedures and direct infection from the maternal peritoneal cavity. Although infection usually follows rupture of amniotic membranes, 1-2% of chorioamnionitis cases occur with intact membranes. We describe a 30-year-old who presented at 18 weeks gestation with fever, intermittent pelvic pain and fetal demise. Placental membranes were intact. There was no evidence of viral infection. Maternal and fetal cord blood cultures grew Staphylococcus aureus. Histopathology was consistent with chorioamnionitis of hematogenous origin. S aureus may be found in the vagina in 12% of pregnancies, but it remains an unusual cause of chorioamnionitis. Only two cases have been reported in the literature, both of which were from an ascending in fection. This is the first case report to describe hematogenous spread of S aureus as the cause of chorioamnionitis. We present this case of S aureus chorioamnionitis that resulted in pre-term labor and fetal demise with intact membranes. The infection was acquired hematogenously.

PERIPARTUM CARDIOMYOPATHY: DIAGNOSIS AND IMPLICATIONS. Catherine L. Long, MD, and Roger DeVersa, MD, University of Tennessee College of Medicine-Chattanooga Unit.

The purpose of this study was to identify theories regarding etiology of peripartum cardiomyopathy, to recognize physical findings of peripartum cardiomyopathy, and to recognize the morbidity and mortality associated with peripartum cardiomyopathy. A 23-year-old white woman, (G1 P1) postcesarean section for fetal distress 2 weeks before presented with increasing shortness of breath for 1 week. She had no significant medical histay and an uneventful pregnancy. Examination revealed tachycardia with a normal [O.sub.2] saturation on room air, elevated neck veins, bibasilar crackles, and a S3 gallop. ECG showed no acute changes. Chest x-ray revealed cardiomegaly with pulmonary venous congestion. An echocardiogram revealed only a dilated left ventricle with an ejection fraction of 15%. Cardiac enzymes were normal. Doppler ultrasound revealed a DVT in the popliteal vein. Despite a normal A-a gradient patient was heparinized. Aggressive trtment for congestive heart failure was initiated. However, she did not show any improvement and 7 days later the patient became hypotensive, and went into asystole. Aggressive resuscitation was unsuccessful. Peripartum cardiomyopathy is defined as the development of heart failure in the last month of pregnancy or within 5 months after delivery without any determinable cause and without previous heart disease before the last month of pregnancy. The etiology of peripartum cardiomyopathy is unknown. Some actually question whether this is a distinct disorder or another form of idiopathic cardiomyopathy. Several ideas have been proposed including an immunologic response to the fetus, increased hemodynamic load of pregnancy, nutrition, and hormone response. Several studies have actually shown that these patients have a high incidence of myocarditis, possibly implicating a viral trigger like enterovirus. Signs and symptoms are typical for congestive heart failure. However, these can sometimes be confused with normal pregnancy. Therefore, peripartum cardiomyopathy may not be diagnosed until pos tpartum. Evaluation would include ECG, chest x-ray, and an echocardiogram. Cardiac catheterization should be considered in those at risk for atherosclerosis. Endomyocardial biopsy remains controversial can be tested for bacterial and viral cultures and Coxsackie B virus titers. Therapy consists of digoxin, diuretics, sodium restriction, and afterload-reducing agents. Thromboembolic phenomena are common, and anticoagulation should be strongly considered. Cardiac transplantation may be considered as well. The morality rate ranges from 25% to 50%. Nearly half of these deaths occur within the first 3 months postpartum. Death is often caused by chronic progressive congestive heart failure, an arrhythmia, or a thromboemolic event. If the patient's heart is to recover, it will usually do so within the first 6 months. If ventricular function does not improve, it is often recommended that the patient not become pregnant again due to the high risk of death.

ACUTE PANCREATITIS ASSOCIATED WITH ORGANIC SOLVENT EXPOSURE. Rebecca McMullen O'Brien, MD, and T. Scott Prince, MD, MSPH. University of Kentucky School of Medicine, Lexington, Ky.

Though not widely recognized, there have been several reports of both acute and chronic pancreatitis associated with exposure to various chemicals, particularly organic solvents. A 23-year-old male had a significant dermal and inhalation exposure to a mixture of methylene chloride and perchlorethylene. He had acute central nervous system symptoms, but these improved rapidly after removal from exposure. However, he developed acute pancreatitis within twenty-four hours of his last exposure. Hospitalized, he recovered rapidly over the next three days and had no persistent abdominal symptoms. Organic solvent exposure may be a risk factor for acute pancreatitis.

USE OF 24-HOUR C-REATIVE PROTEIN LEVEL AS A PREDICTOR OF CULTURE-POSITIVE BACTERIAL ILLNESS IN FEBRILE NEONATES. Joseph H. Chewning, MD. Chattanooga Unit- University of Tennessee College of Medicine.

The current standard of care in pediatrics dictates a complete sepsis wok-up for all febrile neonates, including hospital admission for a minimum of 48-72 hours, complete blood count, urinalysis, lumbar puncture with cerebrospinal fluid (CSF) studies, and cultures of blood, urine, and CSF. While cultures remain the gold standard, there have been numerous studies attempting to identify other methods of predicting sepsis in neonates and reduce hospitalization time. C-Reactive protein (CRP) has been studied extensively in the past as a screening tool for bacterial disease. Delayed or consecutive CRP levels have been shown to have high sensitivity. To our knowledge, there has not been a study in which a single delayed CRP level at 24 hours has been used to predict the absence of bacterial infection in febrile neonates. The purpose of this prospective study is to determine the usefulness of delayed CRP value at 24 hours after admission as a negative predictor of bacterial disease in febrile neonates. All febrile n eonates with CRP obtained at 24 hours by the admitting physician were entered into the study. Forty-four infants born at term ([greater than]37 weeks) with chronological age greater than 2 days and less than 29 days were entered into this study. All of these patients presented to TC Thompson Children's hospital emergency room, outpatient clinic, or general inpatient floor with rectal temperature [greater than]38[degrees]C and no obvious source of bacterial infection by physical exam. Blood, urine, and CSF cultures were monitored by one of the members of the study group until results were finalized. Elevated CRP level was defined as [greater than]0.8 mg/dL. There were positive cultures (blood, urine, and CSF) in only 3 of 44 patients. Each of these patients had an elevated CRP level at 24 hours. Seventeen of 44 patients had elevated CRP levels and negative cultures. The remaining 24 patients had normal CRP and negative cultures. No patient with positive culture had a normal CRP at 24 hours, resulting in 100% s ensitivity. Normal CRP level at 24 hours had a negative predictive value of 100%. Defining the normal CRP value as [greater than]0.8 mg/dL resulted in the high sensitivity, but lowered the specificity to 58% with a positive predictive value of 15%. The results of this preliminary study indicate normal CRP value at 24 hours in a neonate with no obvious source of infection predicts the absence of bacterial infection with 100% sensitivity. Although the sample size is small, these results are encouraging for the use of CRP in evaluating febrile neonates for early hospital discharge.

USE OF ANALGESIA FOR FRACTURES IN CHILDREN. Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia, Richmond.

Fractures in children is a common presentation to an emergency department. The role of adequate analgesia has been evaluated for many different conditions. Evaluation of the use analgesia in the emergency department for children presenting with fractures has been limited. The present study reviews the epidemiology of fractures with a special interest in the adequate pain management of these injuries. Prospective evaluation of all children less than 18 years of age who presented to the pediatric emergency department with a diagnosis of a fracture from August 1998 to August 2000. Fractures that were excluded were those involving the skull or spinal column. There were 492 fractures. The median age was 10.78 [+ or -] 1.64 years (range, 6 weeks to 18 years). There were 430 males (87.4%), 361 (73.3%) African Americans, 114 whites, 9 Asians, and 8 Hispanics. There were a total of 596 fractures, with 104 (17.4%) children having more than 1 fractured bone, and only 2.8% were open fractures. The most common fractures w ere 152 (30.8%) radius, 73 (14.8%) phalanx, 66 (13.4%) ulna, 63 (12.8%) tibia, 57 (11.6%) humerus, 54 (10.9%) fibula, 43 (8.7%) metacarpal, 32 (6.5%) femur, 27 (5.4%) metatarsal, 17 (3.4%) clavicle, 7 (0.1%) scaphoid, and 4 (0.06%) other fractures. In the Salter-Harris Classification of fractures there were 27 (36%) SHI, 38 (50.6%) SH2, 8 (10.6%) SH3, and 2 (2.6%) SH4 fractures. Most buckle type fractures occurred in the radial bone, while more spiral fractures occurred in the tibial bone. The most common mechanisms were fall (54.4%), blunt trauma (23.5%), and twisting (8%). Sport accounted for 21%, with football being the most common with 36% of the fractures. Falls from monkey bars occurred in 8.3% and from bicycles in 5%. Child abuse was suspted in 8 cases. Conscious sedation for fractures occurred in 20.9%, 41.7% received analgesics, with 23% narcotics. Children more likely to receive analgesics were those requiring conscious sedation. Analgesic use for fractures in children is poor. More emphasis in trai ning physicians to use analgesics for children is warranted.

SEVERE THROMBOCYTOPENIC PURPURA AS A COMPLICATION OF CAT SCRATCH DISEASE. Anupama Borker, MD, Renee Gardner, MD, and Rajshekharan Warrier, MD. LSU Health Science Center and Children's Hospital of New Orleans, La.

A 6-year-old girl presented with fever, extensive bruising, and petechiae. She also had shotty, firm cervical lymphadenopathy but no organomegaly. Her platelet count was 1,000, without concurrent anemia or neutropenia. She was treated with intravenous immunoglobulins without resolution of her thrombocytopenia. A bone marrow biopsy showed increased megakaryocytes with normal erythroid and myeloid series. Cat-scratch disease was diagnosed by positive serology for bartonella henselae. She was treated with 10 days of rifampicin and oral prednisone. Within a week, her lymphadenopathy had resolved. Her platelet count increased to 357,000 in 2 weeks. Thrombocytopenia can occur rarely as a complication of cat-scratch disease. However, this is the first reported case of severe thrombocytopenic purpura complicating cat-scratch disease.

LYMPHOPROLIFERATIVE DISORDER IN A NON-TRANSPLANT PATIENT ON TACROLIMUS FOR STEROID-RESISTANT NEPHROTIC SYNDROME. Danette LeBaron, MD, and Michael Grimley, MD, Wilford Hall Medical Center, Lackland Air Force Base, Tex.

Post-transplantation lymphoproliferative disorder (PTLD) is a known complication of long-term immunosuppression after solid organ and stem cell transplants. PTLD has been described with varying rates, with approximately a 9% risk after a renal transplant. In recent years, the use of immunosuppressive therapy has broadened to include various non-transplant patients. Their risk of lymphoproliferative disorder (LPD) has been predicted based on similar exposure to potent immunosuppressive drugs, but has not yet been reported in the literature. We report the case of a 13 year old female with steroid-resistant nephrotic syndrome secondary to focal segmental glomerulosclerosis on tacrolimus therapy for ten years who developed LPD. Despite multiple attempts to remove tacrolimus, her parents refused and she remained on the medication for a prolonged period. The patient presented with a two-week history of constitutional symptoms, lymphadenopathy, and exudative pharyngitis. She was determined to have LPD with an EBV vi ral load of 206,000 copies EBV/mL blood. Her tacrolimus was discontinued and she was started on IV gancyclovir. She initially improved with decreasing EBV copy number and symptoms. However, when her symptoms returned and her EBV copy number rose, granulocyte-macrophage colony stimulating factor (GM-CSF) was added to her therapy. Again she improved clinically for a short time, but eventually relapsed with fevers and bone pain. An evaluation subsequently diagnosed her with B-cell ALL, for which she is currently receiving chemotherapy. This case report is the first known description of a non-transplant patient on tacrolimus who developed LPD. The clinical importance of her case is clear as increasing numbers of patients, including those with nephrotic syndrome, are maintained with potent immunosuppressive agents like tacrolimus. The benefits of tacrolimus therapy for nephrotic syndrome should be carefully weighed against the risks, which now include LPD.

NON-URGENT USE OF THE PEDIATRIC EMERGENCY DEPARTMENT: WHY IT CONTINUES. Muhammad Waseem, MD, and Mary T. Ryan, MD. Lincoln Hospital, Bronx, NY

A large percentage of emergency department (ED) visits are for non-urgent problems. This results in longer waiting times and improper utilization of resources. This study was undertaken to determine why parents continue to use the pediatric ED for non-urgent care of their children. This is a prospective convenience sample study. Physicians administered a short questionnaire to 200 parent or legal guardians of children with minor illnesses. Four questions were asked to determine whether the child had a primary care physician (PCP), if the family had easy access to the PCP and why the child was taken to the ED instead of contacting or visiting the PCP office or clinic. Although most children (96.5%) had a PCP, the majority of caregivers (81.5%) did not have a contact number for the clinic and less than half (46%) actually knew the name of the PCP. A significant difference of opinion exists between caregivers and health care providers about the level of urgency of the presenting complaint. Although all children in this study were triaged as non-urgent ("Category C") visit, over half (50.5%) of caregivers felt that the complaint was an emergency or said they were "afraid to wait" to be seen by their PCP. Of the remaining patients, almost a third (29%) stated their PCP could not see them, as the office was closed or a prior appointment was required. 4.5% reported that they were instructed by their PCP to go the ED. Based on these figures, 88% of these visits were in fact "justified" visits due to inability to access PCP or belief of the caregiver that the problem constituted an emergency. Although most children have a pediatrician, the relationship between the parents and PCP is neither strong nor effective. Lack of communication and limited access to after-hours clinic services account for a significant number of non-urgent ED visits. While differentiation between emergency and non-urgent problems is easy for trained health care providers, for most parents it is not. Appreciation of this fact may help ease the frustr ation generated by non-urgent use of the ED. It may also serve to redirect our energy towards improving our health care system, rather than scorning its casualties. Physicians may have more to learn about over utilization of the ED than patients and their families.

ATV MORTALITY IN KENTUCKY: CAN IT BE PREVENTED? Roger L. Humphries, MD, Thomas M. Huhn, Keith D. Bricking, and C. Keith Stone, MD. Department of Emergency Medicine, University of Kentucky, Lexington.

The purpose of this study was to review all-terrain vehicle (ATV) related deaths in Kentucky and determine if mortality from these accidents can be prevented by improved enforcement and education of Kentucky law. A retrospective observational study was done on fatal ATV accident victims in the Commonwealth of Kentucky between 1996 and 2000. Age, gender, mechanism of injury, location of injury, and position of victim in ATV related deaths in the Commonwealth of Kentucky reported by the United States Consumer Product Safety Commission. Kentucky law, KRS 189.515, regarding operation of ATV's was reviewed. It prohibits operation of ATV's on any public highway or roadway, operation of vehicle on other's property without consent, operation of vehicle when driver is under 16 years old without parental supervision, and restricts usage for persons based on age and engine size. There were 73 ATV related deaths reported with an average age of 24.8 (range, 1-57 years). 87.7% of the deaths were male (average age 26.5) and 12.3% were female (average age 11.5). The most common mechanism of injury was from vehicle rolling over accounting for 46.6%. Other mechanisms of injury included victim thrown from ATV 27.4%, collision with stationary object 13.7%, collision with moving object 5.5%, operator error 1.4%, ATV versus pedestrian 1.4%, and unknown 4.1%. In violation of state law, 58.9% of deaths occurred on streets. Farms accounted for 17.8% of accidents, sports 8.2% and unknown 15.1%. The majority of the victims 89% were drivers of the vehicle, 9.6% passengers and 1.4% pedestrians. ATV accidents continue to result in fatal injuries. The mortality from ATV accidents may be prevented if the current laws regarding ATVs were publicized, observed, and thoroughly enforced.

UTILITY OF THE ELCTROCARDIOGRAM AND THE CHEST RADIOGRAPH IN THE EVALUATION OF CHEST PAINS IN A PEDIATRIC EMERGENCY DEPARTMENT. Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia, Richmond.

Chest pains can be distressing but fortunately in children the majority of causes are not life-threatening. Since most casues are benign in nature, the diagnostic workup for a child presenting with chest pains is controversial. The present study reviews the diagnostic efficacy of both the electrocardiogram and the chest radiograph in children with chest pains. Prospective evaluation of all children less than 18 years of age who presented to our pediatric emergency department with the primary complaint of chest pains. The study period is from August 1998 to August 2000. There were 501 children with chest pains, accounting for 1.1% of the total emergency department visit. There were 255 (50.8%) females, 448 (89.4%) African Americans, 47 (9.3%) whites, 5 Hispanics, and 2 Asians. The most common causes for chest pains were 217 (43.3%) asthma, 98 (19.5%) nontraumatic musculoskeletal pain, 34 (6.7%) contusions, 22 (4.3%) nonspecific chest pains, 22 (4.3%) upper respiratory illness, 13 (2.5%) pharyngitis, 12 (1.9%) sickle cell pain crisis, 8 pneumonia, 8 allergic rhinitis, 5 hyperventilation syndrome, 3 foreign bodies, 2 allergic reactions, 2 supraventricular tachycardias, and 1 sinus arrhythmia. Twelve of the 38 chest radiographs were abnormal. There were 10 patients with pneumonia, 1 pleural effusion and 1 chylothorax. Each of these positive chest radiographs had either fever, unexplained tachypnea, diminished breath sounds or unilateral crackles, or hypoxia. Three of the 44 EGGs were abnormal. There were 2 supraventricular tachycardias and 1 sinus arrhythmia. All of these abnormal ECGs were suspected on clinical examination. There were no ischemic ECG or abnormal QT intervals. Of the 8 children with known cardiac disease, one had supraventricular tachycardia and the other a deterioration of his pulmonary stenosis. The use of an electrocardiogram or chest radiograph in the evaluation of chest pains is of little benefit. Children with abnormalities are usually suspected on the physical examination, such as with the pre sence of fever, abnormal lung examination, abnormal heart rhythm, or hypoxia. Other children who may benefit from these tests may include those with previous heart disease or sickle cell disease.

COMPASSION FATIGUE AND BURNOUT: ARE EMERGENCY NURSES IN A LEVEL ONE TRAUMA CENTER AT RISK? Michael Cull, MSN, Sally Santen, MD, and Larry Prisco. Vanderbilt University Medical Center, Nashville, Tenn.

Emergency nurses are called upon daily to be compassionate toward those in the greatest need. Over time these nurses can become physically and emotionally overloaded by the conditions of human misery. Using the Compassion Satisfaction and Fatigue (CSF) Test developed by Figley & Stamm (1995), the purpose of this study was to determine the level of risk for burn out and compassion fatigue. The CSF is a 66-question survey comparing level of psychological and work satisfaction to level of fatigue and burn out. Demographics and work history were collected. 52 surveys were distributed to emergency department nurses in a level one trauma center and 42 (81%) were returned. Questions were answered using a 6-point likert scale and responses were scored in three sections: 1) Potential for Compassion Satisfaction 2) Risk for burn out and 3) Risk for Compassion Fatigue. 9 men and 39 women were surveyed. Most respondents fell into the 36-40 age range, with 11-15 years of experience. 22 of the respondents were day shift (7 a-7p), 11 were night shift (7a-7p) and 9 were swing shift (3a-3p or 11a-11p). 45% of all respondents were at high (19%) or extreme high (15%) risk for compassion fatigue. 49% of women surveyed were at high (18%) or extreme high risk (30%) versus 33% of men being at high (22%) or extreme high (11%) risk. 15% of all women surveyed were at high risk for burnout versus none of the men. 55% of nightshift respondents were at high or extreme high risk for compassion fatigue versus 50% of dayshift respondents being at high or extreme high risk. 36% of respondents were shown to have a high potential for compassion satisfaction while no respondents showed an extreme high potential for compassion satisfaction. Emergency nurses in a level one trauma center are at risk for compassion fatigue.

ARE ED PATIENTS USING THE INTERNET OR OTHER RESOURCES FOR MEDICAL INFORMATION? Jeanne C. Vogt, Lauren A. Boydston, Aris C. Garro, Sally A. Santen, MD, and Robin R. Hemphill, MD. Vanderbilt University Medical Center, Nashville, Tenn.

Specific medical information is more widely available to the public than ever before, in the form of the Internet, medical books, and journals. The purpose of this study is to 1) determine the frequency with which patients access the Internet and other medical resources in regards to a current ED complaint, and 2) ascertain if the information gathered by patients led them to appropriate self-assessment and treatment. A survey was administered verbally to ED patients or, in pediatric cases, to parents at an academic institution. Respondents were asked about the resources they consulted with respect to their current symptoms prior to presentation to the ED, what they concluded was the cause of the illness, and whether or not they did anything to treat themselves based on that data. The survey also addressed demographics and access to medical information resources. 148 individuals were surveyed, including 97 women and 40 African Americans. 74% of the respondents had consulted some form of source for information prior to arrival at the ED. 54% contacted their physician's office, 27% presented as a result of a pre-existing condition, 26% consulted family or friends, and 1% utilized a medical magazine or journal. Although only 5% consulted the Internet pertaining to their immediate symptoms, 46% reported using the Internet to access medical information at some point. 53% of patients owned medically related books but only 4% had consulted them prior to coming to the ED. Of the people who attempted to determine the cause of their symptoms, 44% were correct, and 83% of those correct had consulted an outside resource. No correlation was seen between accuracy of self-diagnosis and education, gender, income or nature of source. Although patients access the Internet and other written medical resources for general medical information, they do not appear to use them for specific acute/urgent problems. On the other hand, patients do appear to use people (the staff of physician's offices, friends) frequently for medical informati on and advice prior to presentation in the ED.

CHAPERONE PREFERENCES AMONG PEDICATRIC ED PATIENTS AND THEIR PARENTS DURING RECTAL, GENITAL AND PELVIC EXAMS. Irene L. Ho, MS1, Mary Hunt Martin, MS1, Sally A. Santen, MD, Robin R. Hemphill, MD, and Cerine Jeanty. Vanderbilt University, Nashville, Tenn.

When performing rectal, genital, or pelvic exams in pediatric patients it is not always routine practice for physicians to have a chaperone present. The goal of this study is to determine the preferences of pediatric patients and their parents about the use of chaperones for these exams. Prospective survey of pediatric ED patients and parents of their preferences for the use of chaperones. Patients were divided into two groups: preadolescent (ages 8-12) and adolescent (ages 13-18). 91 pediatric patients were surveyed. Of these, 45 were preadolescents (31 boys and 14 girls), and 46 were adolescents (16 boys and 30 girls). Among preadolescents, for a rectal or genital exam by a male physician, 78% of girls and 45% of boys wanted a chaperone. If examined by a female physician, 43% of girls and 65% of boys wanted a chaperone. Appropriate chaperones included mother (girls - 93%, boys - 74%), father (girls - 29%, boys - 71%), or another medical provider (girls - 64%, boys - 19%). Parents of preadolescents had the f ollowing preferences for their children: with male physician, 93% wanted chaperones for the female child, 76% for the male child. With a female physician, 65% wanted a chaperone (same for boys or girls). Among adolescent girls, for a rectal or pelvic exam, 32% wanted a chaperone with a female physician, 70% with a male physician. Appropriate chaperones included mother (63%), father (27%), and another medical provider (57%). Of the parents of adolescent girls, 54% preferred a chaperone with a female physician, 83% with a male physician, (same for rectal and pelvic exams). Among adolescent boys, for rectal exams, 31% wanted a chaperone with a female physician, 25% with a male physician. Appropriate chaperones included mother (69%), father (50%), or another medical provider (25%). For genital exams, 50% wanted a chaperone with a female physician, 31% with a male physician. Appropriate chaperones included mother (50%), father (69%), or another medical provider (43%). Of the parents of adolescent boys, for rectal exam, 81% preferred a chaperone with either a female or male physician. For genital exams, 75% preferred a chaperone with a female physician, while 81% with a male physician. Male and female pediatric patients differ in their preferences for the use of chaperones. Preadolescent children and adolescent girls are more likely to prefer a chaperone if the physician is of the opposite sex. Adolescent boys are less likely to prefer a chaperone except with a female physician performing a genital exam. Distinct discrepancies exist between the child's chaperone preferences and those of his/her parent, especially for male and female teenaged patients.

TRANSFERRED TRAUMA PATIENTS: WHY ARE RADIOGRAPHS REPEATED? Lauren A. Boydston, Cindy B. McCloskey, Megan B. Laniewicz, Sally A. Santen, MD, Robin R. Hemphill, MD, and Jennifer L. Isenhour, MD. Vanderbilt University Medical Center, Nashville, Tenn.

EMTALA requires that when patients are transferred the objective data, including radiographs (x-rays and CT scans), should accompany them to the accepting hospital. Commonly, radiological studies are repeated at the receiving institution increasing both the cost of care and the exposure of the patient to radiation. The purpose of this study is to determine the reasons why the radiographs are repeated in trauma patients. A prospective observational study of trauma patients transferred to a level 1 trauma center was conducted. The ED physician was asked why radiological studies were repeated in the management of transferred trauma patients. The type of radiograph and reason for repeating films was noted. A total of 103 transferred trauma patients were included in the study. Ninety-seven patients had radiological tests performed prior to arrival, of those 85 had some study repeated at the receiving hospital. 59% of chest x-rays, 47% of pelvis x-rays, 57% of spine films, 65% of head CT scans and 36% of abdominal CT's, were repeated by the receiving center. Of the 119 repeated radiological studies, 30% were redone due to poor quality of the accompanying films, 9% because of an incorrect.view, 15% because the original films were not sent with the patient, 23% because of an interval change, and 23% were repeated for no apparent reason. The most common reasons for repeating chest x-rays were for an interval change (39%) or poor quality (26%), whereas the spine films were almost always repeated for poor quality (54%). The studies most often repeated for no apparent reason were the pelvis x-ray (43%) and the abdominal CT (40%). Most radiological tests (82%) that were repeated were necessary from the point of view of the receiving physician, either due to a change in patient status or an inadequacy in the accompanying films. Fifty-five percent of the repeated studies could have been avoided if the transferring facility had sent the films, obtained the correct view, or had included better quality copies or the original radio graphs with the patient.

CHAPERONES FOR RECTAL AND GENITAL EXAMINATIONS: WHAT DO PATIENTS WANT? Naveen Seth, MSII, Sally A. Santen, MD, Robin R. Hemphill, MD, and Keith D. Wrenn, MD. Vanderbilt University Medical Center, Nashville, Tenn.

To compare ED physician practices to patient preferences for the presence of chaperones during genitourinary and rectal exams. At an academic ED, a convenience sample of 163 ED patients with a chief complaint potentially necessitating a rectal or GU exam were surveyed. 52 physicians were surveyed. Ninety-nine women and 64 men were surveyed. While 100% of male physicians responded that they would never do a pelvic without a chaperone, 44% of female patients did not care if a chaperone was present with a male physician. 9% would prefer not to have chaperone. With a female physician, only 25% of women preferred to have a chaperone. Only 92% of female physicians always or most of the time use a chaperone. For rectal exams with male patients, only 5% of male physicians always or most of time used a chaperone, while 15% of female physicians did. Few male patients preferred to have a chaperone (1-2%). When asked the gender of the chaperone, 23% of physicians felt that a male chaperone would be acceptable for a pelvi c exam. 69% of female patients felt that a male chaperone was acceptable with a male physician. When female patients were asked who is an appropriate chaperone a friend (46%), a family member (68%) or a medical provider (83%) were all considered to be appropriate. About 70% of patients would like to be asked their preference for a chaperone, while only 27% of physicians said that the patient's preference would change their practice. Patients and physicians differ on their preference for the use of chaperones. Especially for male physician performing pelvic exams, a significant number of women did not feel a chaperone was necessary.

PRIMARY, ACUTE, AND EMERGENCY CARE CONSIDERATIONS RELATED TO PEACE KEEPING OPERATIONS IN SOUTH AMERICA. Shawn F. Taylor, MD, Robert H. Lutz, MD, and John A. Millward, PA-C, MS. 7th Special Forces Group (Airborne), Fort Bragg, NC.

In the last decade, peacekeeping operations and training for peace keeping missions required more military, civillian, and non-governmental organization support than in the entire forty years preceding it. While literature exist describing mortality, disease, injury, and medical support for peacekeeping operations in Europe, Africa, the Caribbean, and the Far East, none was found concerning operations and training for peacekeeping in South America. This retrospective study presents an analysis of disease and injury for personnel participating in CABANAS 2000, an eight-nation peacekeeping exercise held in Argentina. 1500 personnel, including foreign nationals, U.S. Military, and civillian organizations participated. The mean disease/injury rate for the 6-week period was 4.1 cases/100 personnel/week. Frequently cited causes for participant presentation for medical treatment were resipiratory disease (43%), orthopedic disorders and injuries (25.9%), other miscellaneous medical conditions (8.5%), dermatological c omplaints (6.9%), and diarrhea and intestinal complaints (6.5%). In addition, other presentations required the use of host nation emergency and specialist consultation, in-patient services, and air evacuation to the U.S. This article also addresses concerns regarding the planning, preparation, and supporting of peacekeeping operations in underdeveloped South American Nations.

EMTALA REQUIRED TRANSFER PAPERS: ARE TRAUMA PATIENTS TRANSFERRED WITH APPROPRIATE PAPERWORK? Megan B. Laniewicz, Jeanne C. Vogt, Cindy B. McCloskey, Sally A. Santen, MD, Robin R. Hemphill, MD, and Jennifer L. Isenhour, MD. Vanderbilt University Medical Center, Nashville, Tenn.

EMTALA requires that patients transferred from one hospital to another must be accompanied by specific paperwork to facilitate patient care. The purpose of this study is to determine compliance with EMTALA in the transfer of trauma patients to a level 1 trauma center. Prospective data was collected from patients transferred to a level 1 trauma center, with 65,000 visits, from non-trauma centers. The following data was collected from 103 transferred trauma patients: patient or family signature on transfer forms, patient's ability to sign, presence of nursing and physician notes, lab work, and radiographs. The rates of compliance were determined. 71% of transfer forms were signed by patient or family member. 33% of the 30 patients who did not sign were in fact capable of signing the transfer form. In 14% of the cases, nursing notes were not sent to the receiving hospital. In addition, in 19% of the cases, physician notes were not sent. Of the 70 patients who had lab work done at the transferring hospital, the r esults of labs were not sent 20% of the time. Of the 93 patients who had x-rays taken at the outside hospital, the receiving hospital did not receive all of the x-rays 19% of the time. However, of the 48 patients who had CT scans taken at the transferring hospital, the receiving hospital did not receive all of the CT scans 6% of the time. Of the 103 total patients studied, 54% had at least one EMTALA violation. Although most of the time individual EMTALA standards are not being violated by the transferring hospitals, in the majority of cases, at least one EMTALA standard is being violated per transferred patient. Clearly EMTALA is effective at encouraging hospitals to send all specific paperwork necessary to facilitate patient care, but total compliance is necessary to maintain standard of care.

ANALYSIS OF CURRENT EMERGENCY MEDICINE ULTRASOUND TRAINING. Glynis A. Walsh, MD, and Jennifer Isenhour, MD. Vanderbilt University School of Medicine, Nashville, Tenn.

The objective of this study was to assess current educational techniques employed by emergency medicine (EM) residency programs in teaching ultrasound (US) from 1994-2000. A survey was sent to residency coordinators and program directors of 122 EM residencies in the United States. Responses concerning methods and types of US training, as well as core curriculum versus US electives were tabulated. Approximate hours of instruction in US were determined. Overall response rate was 61% (75). Of the 62 programs with US training from 1994-2000, 95% (59) utilized lectures, 81% (50) used hands on teaching with models, 89% (55) employed bedside training, and 55% (34) offered training in other departments (i.e. radiology, OB/GYN). Eighty four percent taught US using at least 3 of the above modalities. Ninety five percent (59) teach trauma FAST scan, 87% (54) AAA, 74% (46) RUQ/Gallbladder, 71% (44) transthoracic/cardiac, 65% (40) transvaginal, 56% (35) renal, and 18% (11) lower extremity DVT. More than 3 different US typ es are demonstrated at 76% (47) of institutions. Ninety four percent of programs incorporate US into their core curriculum and 53% offer it as an elective. The average hours of US instruction were 29. Most EM programs are actively using multiple methods to train their residents in a number of US techniques. As of yet, there is no consensus on the required elements of US training for EM.

DIAGNOSTIC STRATEGIES IN ACUTE CHOLECYSTITIS. Lisa Morrison, MD, and Trevor Mills, MD. Southwest Medical Center, Dallas, Tex.

The objective of this study was to determine the significance of physical exam findings and lab data in the setting of suspected acute cholecystitis (AC). The study design was a retrospective chart review in a high volume urban county hospital. Subjects included all patients between 18 and 65 years of age presenting with a chief complaint of right upper quadrant (RUQ) pain who were referred for emergent ultrasound of the gall bladder. Study period extended from November 1, 1999 to January 31, 2000. Patients were categorized into 2 groups, AC and not AC. Diagnosis of AC was confirmed by RUQ ultrasound. Statistical method was a chi squared analysis to determine significant predictors of multiple parameters. Logistic regression models were employed to determine the statistical significance of these predictors. Parameters included fever, liver function tests, white blood cell count (WBC), and clinical Murphy's sign. The charts of 96 patients were reviewed, 35% male, 65% female. Thirty-seven percent (n=18) of pati ents had ultrasonographic evidence of AC (71% female, 29% male). One hundred percent of patients diagnosed with AC, reported nausea and vomiting in the last 24 hours. Eighty-four percent of patients with both, elevated alkaline phosphatase and total bilirubin were diagnosed with AC. Eighty-nine percent of patients with AC had a positive Murphy's sign. Fever (temperature [greater than] 37.9[degrees]C) was present in 67% of patients with AC. Hyperglycemia (serum glucose [greater than] 120 mg/dL) present in 60% of patients with AC. Alkaline phosphatase, AST, ALT, GGT, and total bilirubin were elevated in greater than 50% or patients with AC. Of note, 61% of patients with AC had normal WBC at presentation. In the clinical setting of RUQ pain no single physical exam finding or laboratory study definatively indicates the presence or absence of AC. However, the dual finding of elevated alkaline phosphatase and total bilirubin is highly suggestive of AC. Fever and history of nausea/vomiting each are strongly indicati ve of AC.

PEDIATRIC HEAD INJURY DISCHARGE INSTRUCTIONS. Muhammad Waseem, MD, and Mary T. Ryan, MD. Lincoln Hospital, Bronx, NY

The guidelines for the management of moderate to severe head injuries are well defined. The management of minor head injuries however continues to generate controversy. We undertook a study to compare the discharge instructions for minor head injury given by various pediatric emergency departments (ED) and to examine whether parents of children sustaining head trauma are receiving appropriate ED discharge instructions. This study was an observational study in which 80 pediatric EDs were contacted by mail. The centers contacted were those having pediatric residencies or pediatric emergency medicine fellowship programs. Each department was asked to provide a copy of their written discharge instructions for minor pediatric head trauma. We had a response rate of 63% (n= 51). We then examined the content of the instruction sheets and compared the "Symptoms to Observe" and "Advice for Parents" outlined, The head injury discharge instruction sheets showed the following as "What to Observe": sleepiness 98%, difficulty in awakening 98%, persistent vomiting 95%, headache 88%, unsteadiness 86%, blurred vision 86%, seizures 77%, change in behavior/increased crying 74%, inequality of pupils 67%, weakness of arms or legs 56%, bleeding or clear discharge from the nose 51%, bleeding or clear drainage from the ears 49%, slurred speech 42%, neck stiffness 33%, fever 23%, irritability/restlessness 19%, swelling/lump 4.7%, bleeding from the mouth 2.3%, and incontinence 2.3%. The head injury discharge instruction sheets showed the following as "Advice for Parents": rest for 24 hours 85%, wake child every 34 hours 83%, acetaminophen for headache 40%, and light diet for 24 hours 33%. The discharge instructions sheets we examined consistently focused on findings which are known to be late manif estations of significant intracranial injury. Although some inconsistencies were found between the discharge instruction sheets, no conflicting advice was offered by any of them. There is still a need to develop a uniform instruction sheet for children with minor head trauma. Emphasis should be placed on early symptoms rather than late findings to ensure a prompt return visit to the ED if the need arises. The introduction of a national head injury discharge instruction sheet would ensure consistency of care and could further improve the quality of care provided.